summary of the article

Neurogastroenterology & Motility. 2018;30:e13158. wileyonlinelibrary.com/journal/nmo  |  1 of 8 https://doi.org/10.1111/nmo.13158

© 2017 John Wiley & Sons Ltd

Received: 19 December 2016  | Accepted: 15 June 2017 DOI: 10.1111/nmo.13158

O R I G I N A L A R T I C L E

Esophageal function testing: Billing and coding update

A. Khan1  | B. Massey2 | S. Rao3 | J. Pandolfino4

1Division of Gastroenterology, New York University School of Medicine, New York, NY, USA 2Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA 3Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia 4Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

Correspondence Abraham Khan, MD, Division of Gastroenterology, New York University School of Medicine, New York, NY, USA. Email: [email protected]

Abstract Background and Purpose: Esophageal function testing is being increasingly utilized in diagnosis and management of esophageal disorders. There have been several recent technological advances in the field to allow practitioners the ability to more accurately assess and treat such conditions, but there has been a relative lack of education in the literature regarding the associated Common Procedural Terminology (CPT) codes and methods of reimbursement. This review, commissioned and supported by the American Neurogastroenterology and Motility Society Council, aims to summarize each of the CPT codes for esophageal function testing and show the trends of associated reim- bursement, as well as recommend coding methods in a practical context. We also aim to encourage many of these codes to be reviewed on a gastrointestinal (GI) societal level, by providing evidence of both discrepancies in coding definitions and inadequate reimbursement in this new era of esophageal function testing.

K E Y W O R D S

billing, coding, impedance testing, manometry, pH testing

1   |   I N T R O D U C T I O N

Esophageal function testing is essential for evaluating dysphagia, non- cardiac chest pain, symptoms suggestive of gastroesophageal reflux, as well as patients before and after esophageal surgery. In recent years, there have been several technological advances in these diagnostic examinations. However, coding and reimbursement have not kept up with the advances, potentially limiting the appropriate use of these pro- cedures in routine clinical practice. Similarly, there is a relative lack of reference materials in the literature to guide the individual practitioner.

A position paper from the American Motility Society discussed the relevant procedures and codes in detail in 2003,1 but there have been no updates or reviews for over a decade. Similarly, the American Society for Gastrointestinal Endoscopy (ASGE) provided a review on esopha- geal manometry and multichannel intraluminal impedance (MII) with pH monitoring and associated reimbursement in 2012,2 but they have not discussed wireless esophageal pH testing in a comprehensive tech- nological report since 2005.3 Lastly, the American Gastroenterological Association (AGA) provided a guide on coding esophageal manometry testing in a quarterly practice newsletter in 2012,4 but has not oth- erwise officially provided recommendations. Consequently, at pres- ent, there is a dearth of information on how to correctly bill and code

for these procedures, whether physicians and institutions performing these procedures are adequately compensated for their services, and lastly what the unmet needs are for reimbursement in this field.

The aims of our review were to:

• Briefly outline the Common Procedural Terminology (CPT) pro- cess to provide a context for the development of current codes for esophageal function testing.

• Define each of the codes individually, show the recent trends in Medicare payments, and enumerate the work involved in per- forming these procedures, especially with the advent of newer technology.

• Provide guidance for the reporting of these codes, in the setting of recent advances in the procedural technology.

2   |   C P T P R O C E S S

The CPT system was developed by the American Medical Association (AMA) in 1966, with each medical procedure being assigned a code. The CPT code set is governed and copyrighted by the AMA and pub- lished yearly. The AMA website details the process of obtaining a

2 of 8  |     KHAN et Al.

new CPT code for a procedure, or changing an existing code.5 The request is referred to an advisory committee, which can then initiate a multistep process ending in approval, postponement, or rejection.

In the 1990s, Medicare reimbursement transitioned to a resource- based practice expense relative value for each CPT code that differs based on the site of service.6 Each CPT code is assigned a relative value unit (RVU), and each RVU has separate components for physician work (work RVU or wRVU), practice expense, and professional liability insur- ance, as well as individual geographic conversion factors. The values are based on evaluation by the AMA Relative Value Update Committee (RUC) as well as survey data from physicians in each field. The RUC makes recommendations to the Center for Medicare and Medicaid Services (CMS), which ultimately defines the Medicare Physician Fee Schedule and appropriate payments.

The process for changing RVUs or CPT codes is lengthy. If the AMA application request is approved, a detailed practice survey is conducted by specialties whose members most commonly perform the service, with a minimum of 30 respondents rating all the service characteristics of the procedure being evaluated. The relevant spe- cialty society then presents a summary of the data and recommenda- tions to the AMA RUC. The RUC will next make its recommendation to CMS regarding the procedure in question. Currently, there are no gastroenterologists on the AMA RUC. Furthermore, with gastrointes- tinal (GI) societies largely focusing on reimbursement cuts for upper endoscopy and colonoscopy in recent years, little attention has been given to other procedures, including esophageal function testing.

3   |   C P T C O D E S : E S O P H A G E A L F U N C T I O N T E S T I N G

Table 1 reveals the current CPT codes for esophageal function test- ing. Since the aforementioned position paper of the American Motility Society in 2003,1 several new and revised codes have been released.

In 2005, pH testing garnered new codes 91034 and 91035, while esophageal function testing using impedance led to the development of 91037 and 91038. In 2011, there was a change to the descrip- tor for 91010, an add- on code 91013 to report esophageal motility with stimulation or perfusion, and two new category III codes (0240T, 0241T) for reporting high- resolution esophageal pressure topography (HREPT).7 Lastly, in 2016, the esophageal balloon distension study 91040 was clarified as a diagnostic procedure, and not just a provo- cation procedure.8 Table 1 defines the updates on all of these codes. Of note, if office visits are combined with esophageal function tests in the same clinical visit, an appropriate office visit modifier should be added.

Tables 2 and 3 display recent reimbursement for these esophageal codes, after download from the CMS website (https://www.cms.gov/ apps/physician-fee-schedule/search/search-criteria.aspx) and using other public references listed. Of note, esophageal motility and reflux testing typically occur in two settings: Facility (i.e., Physician Office) and Hospital Outpatient. These tests are typically not covered in an Ambulatory Surgery Center (ASC), with the exception of 91035 as shown in Table 3.

Key Points • There has been a lack of guidance in the literature on cod-

ing and reimbursement for esophageal function testing. • This review describes each of the CPT codes for esopha-

geal function testing and recommends billing and coding methods in the current environment.

• This review shows limitations in the current coding defini- tions and reimbursement for esophageal function testing, and it presents an opportunity for review on a GI societal level.

TABLE 1 Current definitions of codes for esophageal function testing

Esophageal function test

91010 Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report

+91013 With stimulation or perfusion (e.g., stimulant, acid, or alkali perfusion) (List separately in addition to code for primary procedure) (Use 91013 in conjunction with 91010)

0240T Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with three- dimensional high- resolution esophageal pressure topography (Do not report 0240T in conjunction with 91010)

0241T With stimulation or perfusion during three- dimensional high- resolution esophageal pressure topography study (e.g., stimulant, acid, or alkali perfusion) (List separately in addition to code for primary procedure) (Use 0241T in conjunction with 0240T) (Do not report 0241T in conjunction with 91010)

91034 Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis, and interpretation

91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis, and interpretation

91037 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis, and interpretation

91038 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis, and interpretation; prolonged (greater than 1 h, up to 24 h)

91040 Esophageal balloon distension study, diagnostic, with provocation when performed

     |  3 of 8KHAN et Al.

TABLE 2 2014, 2015, 2016 RVUs and reimbursements for esophageal function tests

Physician practice

CPT/HCPCS Fee Modifier Physician work RVUs

Practice expense RVUs Malpractice RVUs Total RVUs

Medicare National Average Allowable

2014

91010 Global 91010 1.28 3.61 0.08 4.97 $178.04

Professional 26 1.28 0.58 0.07 1.93 $69.14

Technical TC 0.00 3.03 0.01 3.04 $108.90

91013 Global 91013 0.18 0.47 0.02 0.67 $24.00

Professional 26 0.18 0.08 0.01 0.27 $9.67

Technical TC 0.00 0.39 0.01 0.40 $14.33

91034 Global 91034 0.97 4.32 0.05 5.34 $191.29

Professional 26 0.97 0.44 0.04 1.45 $51.94

Technical TC 0.00 3.88 0.01 3.89 $139.35

91035 Global 91035 1.59 11.91 0.08 13.58 $486.47

Professional 26 1.59 0.71 0.07 2.37 $84.90

Technical TC 0.00 11.20 0.01 11.21 $401.57

91037 Global 91037 0.97 3.51 0.08 4.56 $163.35

Professional 26 0.97 0.44 0.07 1.48 $53.02

Technical TC 0.00 3.07 0.01 3.08 $110.33

91038 Global 91038 1.10 11.57 0.06 12.73 $456.02

Professional 26 1.10 0.50 0.05 1.65 $59.11

Technical TC 0.00 11.07 0.01 11.08 $396.92

91040 Global 91040 0.97 10.25 0.04 11.26 $403.36

Professional 26 0.97 0.41 0.03 1.41 $50.51

Technical TC 0.00 9.84 0.01 9.85 $352.85

2015

91010 Global 91010 1.28 3.65 0.10 5.03 $179.85

Professional 26 1.28 0.57 0.09 1.94 $69.36

Technical TC 0.00 3.08 0.01 3.09 $110.48

91013 Global 91013 0.18 0.48 0.02 0.68 $24.43

Professional 26 0.18 0.08 0.01 0.27 $9.70

Technical TC 0.00 0.40 0.01 0.41 $14.73

91034 Global 91034 0.97 4.30 0.05 5.32 $190.22

Professional 26 0.97 0.42 0.04 1.43 $51.13

Technical TC 0.00 3.88 0.01 3.89 $139.09

91035 Global 91035 1.59 12.01 0.10 13.70 $489.84

Professional 26 1.59 0.70 0.09 2.38 $85.10

Technical TC 0.00 11.31 0.01 11.32 $404.74

91037 Global 91037 0.97 3.54 0.07 4.58 $163.76

Professional 26 0.97 0.43 0.06 1.46 $52.20

Technical TC 0.00 3.11 0.01 3.12 $111.55

91038 Global 91038 1.10 11.69 0.10 12.89 $460.88

Professional 26 1.10 0.49 0.09 1.68 $60.07

Technical TC 0.00 11.20 0.01 11.21 $400.81

91040 Global 91040 0.97 11.44 0.04 12.45 $445.15

Professional 26 0.97 0.44 0.03 1.44 $51.74

Technical TC 0.00 11.00 0.01 11.01 $395.63

(Continues)

4 of 8  |     KHAN et Al.

When in the Physician Office, if the equipment is owned by the physician, the equipment and physician fees are billed under the global code if the procedure, analysis, and interpretation are all performed in this setting. In the hospital outpatient setting, the equipment and proce- dure expenses are divided into two modifiers: the technical component (TC) modifier represents the expenses incurred performing the proce- dure and is billed by the hospital, while the 26 modifier represents the physician component which includes analysis and interpretation. In the hospital outpatient setting, equipment and practice expenses are billed by the hospital using APC codes that are mapped to the appropriate CPT code for the test performed. Medicare sets guidelines as to which CPT and APC codes may be combined in this instance. With the advent of solid- state digital high- resolution manometry (HRM) catheters and motility workstations, the costs associated with the TC modifier have increased considerably over those associated with low- resolution per- fused manometry systems on which the total RVU values for 91010 were originally developed.

With technological advances in esophageal function testing, many of the CPT codes now represent procedures that may be combined in

the same patient visit. This, along with the lack of consensus recom- mendations on billing and coding for these procedures, further confuses physicians and billers. We aim to provide transparency on obtaining re- imbursement for these procedures in the following section, by review- ing each relevant GI procedure and its associated CPT code(s), while also offering coding suggestions in the current billing environment.

3.1 | Esophageal manometry

Esophageal manometry testing is primarily indicated in the evaluation of non- obstructive dysphagia, non- cardiac chest pain, before antireflux surgery, and to determine the precise location of the lower esophageal sphincter for other examinations. This testing has undergone significant advances in the past decade, with the advent of HRM. This has largely replaced conventional manometry in academic centers and has gained wide acceptance. In HRM, catheters with pressure sensors spaced 1- 2 cm apart are positioned to span the entire length of the esophagus so that pressures generated can be measured simultaneously. Software converts the pressure data to generate esophageal pressure topography

Physician practice

CPT/HCPCS Fee Modifier Physician work RVUs

Practice expense RVUs Malpractice RVUs Total RVUs

Medicare National Average Allowable

2016

91010 Global 91010 1.28 3.60 0.09 4.97 $177.95

Professional 26 1.28 0.55 0.08 1.91 $68.39

Technical TC 0.00 3.05 0.01 3.06 $109.56

91013 Global 91013 0.18 0.46 0.01 0.65 $23.27

Professional 26 0.18 0.08 0.01 0.27 $9.67

Technical TC 0.00 0.38 0.00 0.38 $13.61

91034 Global 91034 0.97 4.30 0.08 5.35 $191.55

Professional 26 0.97 0.42 0.07 1.46 $52.27

Technical TC 0.00 3.88 0.01 3.89 $139.28

91035 Global 91035 1.59 11.82 0.13 13.54 $484.79

Professional 26 1.59 0.68 0.12 2.39 $85.57

Technical TC 0.00 11.14 0.01 11.15 $399.22

91037 Global 91037 0.97 3.49 0.06 4.52 $161.84

Professional 26 0.97 0.42 0.05 1.44 $51.56

Technical TC 0.00 3.07 0.01 3.08 $110.28

91038 Global 91038 1.10 11.49 0.07 12.66 $453.28

Professional 26 1.10 0.47 0.06 1.63 $58.36

Technical TC 0.00 11.02 0.01 11.03 $394.92

91040 Global 91040 0.97 11.24 0.04 12.25 $438.60

Professional 26 0.97 0.42 0.03 1.42 $50.84

Technical TC 0.00 10.82 0.01 10.83 $387.76

CMS Fee Schedule Lookup last accessed November, 2016 https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. CY2014 Hospital Outpatient Perspective Payment System Final Rule, CMS- 1601- FC, effective January 1, 2014. CY2015 Hospital Outpatient Perspective Payment System Final Rule, CMS- 1613- FC, effective January 1, 2015. CY2016 Hospital Outpatient Perspective Payment System Final Rule, CMS- 1633- FC, effective January 1, 2016. RVUs, relative value unit; HCPCS, Healthcare Common Procedure Coding System ; CPT, Common Procedural Terminology.

TABLE 2  (Continued)

     |  5 of 8KHAN et Al.

(EPT) plots, and these plots are subsequently analyzed according to the Chicago Classification of esophageal motility disorders. The classifica- tion has been updated periodically in the past several years by an in- ternational working group, factoring in updates in clinical and research experience.9 The Chicago Classification is based on the analysis of 10 supine liquid swallows with 5 mL of water; however, other components can be added to this protocol to supplement clinical interpretation of esophageal motility. One expert revealed an institutional protocol that added upright liquid swallows, multiple rapid swallows, and provocative swallows with both a thick liquid and solid food bolus.10

With the potential for further standardization of this procedure, and supplemental components that would add to procedure time, appropri- ate representation of RVUs for this procedure needs to be monitored and supported on a GI societal level. As no code currently exists to reflect high- resolution esophageal manometry with topography, we propose a need for reassessment of 91010 to reflect the advances of both this tech- nology and the associated test interpretation. Currently, 91010 is the CPT code that should be submitted for esophageal manometry. If a stim- ulant is performed, which is not routinely recommended in the Chicago Classification, 91013 should be submitted as well. As in the definition in Table 1, 91013 does not specify the entirety of possible stimulants that can be used. We believe that in post- prandial esophageal manom- etry studies, when looking for rumination and belching syndromes, this should be modified to include a meal and post- prandial analysis.

Lastly, 0240T and 0241T represent codes if three- dimensional EPT is used during the manometric test. This is a potential promising area of esophageal function assessment, but there has been a relative lack of literature translating its utility into clinical practice.11 At pres- ent, CMS has not established specific reimbursement for codes 0240T and 0241T, and thus, reimbursement is carrier priced. Furthermore, without a clear clinical indication for this test, we recommend it cur- rently be pursued only as a research endeavor.

3.2 | Esophageal manometry with impedance

High- resolution manometry catheters can also incorporate impedance sensors, which detect the presence of liquid or air movement by measur- ing changes in electrical resistance. This is important in assessing bolus transit and also has been deemed valuable in suggesting rumination and supragastric belching.10 Current software allows for the impedance information to be assessed during the same 10 supine liquid swallows necessary for the HRM test. Because both liquid and viscous boluses are routinely analyzed, this will prolong the time of the procedure. Use of commercially prepared boluses that can be detected by the impedance system will add to costs billed under the TC component of the procedure, as will the higher purchase and maintenance costs associated with the use of catheters that contain both manometric and impedance sensors.

When esophageal manometry with impedance is performed, both 91010 and 91037 can be billed separately. The CMS Correct Coding Initiative (CCI) has no edit barring reporting these together. The greatly enhanced information provided by being able to analyze and interpret concurrent manometric and impedance information comes, however, at a greater work effort. With expanding literature on the utility of esophageal T

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6 of 8  |     KHAN et Al.

manometry with impedance testing, future adequate reimbursement for 91037 when performed and interpreted concurrently with esophageal manometry is another area of priority for esophageal function testing.

3.3 | Esophageal balloon distension

As mentioned above, 91040 originally was a code for a provocation study using an esophageal balloon. Recent advancements in balloon- based esophageal function testing have now yielded a functional lumen imaging probe that relies a balloon mounted on a catheter placed at the time of an upper endoscopy. This system uses imped- ance planimetry to measure the cross- sectional area and pressure of the esophagus under while under distension. In recent years, there have been several publications showing the increase use of this tech- nology in a variety of esophageal disorders, and even evidence that the diagnostic component of the technology can guide treatment.12 Currently, the use of this technology is a clinical consideration in the workup of non- obstructive dysphagia or non- cardiac chest pain, as well as in the management of gastro- esophageal reflux disease (GERD), eosinophilic esophagitis, or achalasia.

3.4 | Wireless pH testing

In recent years, wireless pH tests have become an alternative to transna- sal ambulatory pH monitoring and now have the potential to record data for up to 96 hours. These tests are indicated in the workup of GERD. With burgeoning literature regarding potential proton pump inhibitor (PPI) side effects, new medical and surgical approaches to GERD, and a lack of response to PPIs in a sizable amount of patients, baseline evalu- ation of esophageal acid exposure is becoming increasingly important.

91035 is the correct code for this procedure. When performed on endoscopy, the endoscopy code can be billed on the day of the proce- dure, and the 91035 billed on the date the data are retrieved. Of note, if performed with manometry testing on the same day, 91010 can be billed in standard fashion. However, if manometry is done with imped- ance, 91037 will be bundled with 91035, and only 91035 should be reported. In this instance, CCI does not allow to override this edit with a modifier. As the wireless pH test and manometry with impedance test are two separate procedures with different indications, this is an area in need of change and GI societal assessment.

3.5 | Catheter- based pH and impedance- pH testing

Traditionally, transnasal ambulatory pH catheters measure esopha- geal and even gastric pH over a period of up to 24 hours, and 91034 has been the correct code for this procedure. As with wireless pH tests, these tests should be done while off PPI therapy.

Transnasal pH catheters now also have the ability to add impedance sensors, and this combined impedance- pH testing can assess reflux as acidic, weakly acidic, or non- acidic, as well as correlate the reflux to symp- toms, usually over a period of 24 hours of evaluation.2 Impedance- pH testing is now recommended in assessing a patient for refractory GERD while on PPI therapy, and can still be done off PPI as well.13

When an impedance- pH test is performed, either 91034 or 91038 can be billed, but not both, as again the impedance test will be bun- dled into the pH test. Furthermore, as with wireless pH testing, nei- ther 91034 nor 91038 can be billed on the same day that 91037 is performed. This is likely due to the historical descriptions of 91037 and 91038 both being methods of measuring gastroesophageal re- flux, and differing only in their duration. This was probably a rea- sonable restriction at the time these definitions were proposed, in order to avoid taking a continuous 24- hour reflux study and billing this as separate < 1- hour and 23- hour studies. However, 91037 is now an impedance- based assessment of bolus transport, not primar- ily gastroesophageal reflux, and the hardware, software, and analytic process are completely distinct from what is performed with 91038. Furthermore, the definition of 91038 does not incorporate the con- current recording and analysis of ambulatory pH data, which is now the standard of care. Given this reality, the difference in wRVUs of 0.13 between 91034 and 91038 (which translates into a difference in Medicare reimbursement of <$5 in 2016) is inappropriate. Practically, as 91038 is now a test that requires significant time for interpretation and expertise above that of pH testing alone (91034), an appropriate increase in the physician component of reimbursement for 91038 is recommended.

Currently, if an esophageal manometry test (with or without im- pedance) is performed the same day as an impedance- pH catheter is placed, it is suggested to bill 91010 on the day of the manometry study, and 91034 or 91038 on the following date, when the imped- ance- pH test is completed and the data are first available for analysis. Furthermore, if stationary impedance (91037) is performed concur- rently with the esophageal manometry study (91010) and both are billed for that day, then if on that day a separate 91034 or 91038 procedure is subsequently initiated, it is imperative to have a sepa- rate encounter in the medical record on the following day (encounter for data download/retrieval) to which the 91034 or 91038 procedure report is linked, with billing occurring on this second day. While this seems to be a reasonable approach, its success among different in- surance vendors is uncertain at this time. In addition, some insurers do not routinely reimburse for 91038 when an impedance- pH test is performed, and only 91034 can be coded. Lastly, reimbursement for 91034 and 91038 can certainly vary by carrier, and this should also be a consideration when coding for the procedure performed.

Given the above considerations, the following new definitions for CPT coding terminology are suggested:

91037: Esophageal Function test, esophageal bolus transport test with stationary nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; may be performed concurrently with 91010. 91038: Esophageal Function test, gastroesophageal reflux test with ambulatory nasal catheter intraluminal pH and impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 24 hours).

     |  7 of 8KHAN et Al.

There should also be consideration for a completely new CPT code that describes the performance and analysis of concurrent HRM/EPT and intraluminal impedance assessment of esophageal bolus transport.

3.6 | Oropharyngeal and aerosolized reflux testing

Technology to include oropharyngeal pH monitoring for the detec- tion of liquid and aerosolized supraesophageal gastric reflux has now been developed and uses 91034 as well.14 However, there has been a lack of publications showing that aerosolized reflux testing can pre- dict clinical outcome, and further studies to define the utility of this technology are needed.

3.7 | Provision for repeat analysis and interpretation of previously acquired esophageal function test data

A key component of esophageal function testing is that it yields a re- port summarizing the test findings and their diagnostic implications. These reports typically contain summary statistics of the parameters measured, including those generated by algorithms within the analysis software that is typically included as a component of the commercial motility systems. These reports do not contain the entirety of the pri- mary data in a form that can be re- analyzed. However, the primary data are typically contained in digital files that can be sent via email or portable media storage devices to other institutions possessing the same primary motility software. This is analogous to sending digitized radiographic studies from one institution to another.

While automated analyses are available in different software pack- ages, these are not a substitute for an experienced clinician reviewing the primary data, as there is a learning curve for the correct interpre- tation of these examinations. Unfortunately, there has been a prolifer- ation of inexperienced clinicians performing esophageal function tests and relying solely on the summary data generated by the software when finalizing the interpretive report. This can result in such errors as interpreting a pH sensor detaching and falling into the stomach as an abnormally long period of esophageal acid exposure, or a pressure- drift artifact as esophageal outflow obstruction on manometry. These errors cannot usually be identified in the procedure report, but only by a new review of the primary test data.

We recommend a provision to allow billing of the professional component (26 modifier) alone when a completely new analysis and interpretation are performed on the primary data of a previously com- pleted esophageal function test. This would be analogous to pathol- ogists re- reading histologic slide sets or radiologists re- reading CT scans. This would require generation of a new report for the medical record, which should include an explanation for agreement or dis- agreement with the previous interpretation.

3.8 | Endoscopically assisted catheter placement

There are many patients in whom routine placement of test catheters transnasally, without imaging assistance, is unsuccessful. Reasons for

failure include hyperactive gag reflexes, extreme anxiety, upper airway anatomy, and post- operative anatomy at the gastroesophageal junc- tion. These patients may require endoscopically guided placement of the catheter. When this is necessary, there is a specific endoscopic CPT code that can be billed: 43241 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jeju- num as appropriate; with transendoscopic intraluminal tube or catheter placement).

4   |   C O N C L U S I O N

Esophageal function testing is indicated for the diagnosis and management of a variety of upper GI symptoms and conditions. Recent technological advances have allowed GI practitioners to better assess and treat esophageal motility disorders and GERD, but there is a lack of education in the literature regarding the as- sociated CPT codes and methods of reimbursement. This article reviewed each of the CPT codes for esophageal function testing and their current reimbursement, while also proposing methods of coding for these procedures in a practical context, at least for cur- rent practice within the United States. However, the inability of physicians to obtain appropriate reimbursement for the costs and efforts involved in performing state- of- the- art esophageal func- tion testing is a source of increasing frustration that may have a negative effect on recruiting and retaining practitioners in the field. Because the current CPT definitions do not accurately re- flect the costs and physician work involved in esophageal function studies, there is a great need for these to be re- evaluated by the RVRBS Committee of the AGA. We believe an ongoing dialog with CMS, together with revision of codes and/or development of new codes, will help to streamline the reimbursement and bring this process in line with current clinical practice, as well as adequately remunerate physicians and institutions providing these invaluable services.

CONFLICT OF INTEREST

One author (JP) is a consultant for Medtronic and Diversatek.

A U T H O R C O N T R I B U T I O N

All authors contributed to writing the paper.

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How to cite this article: Khan A, Massey B, Rao S, Pandolfino J. Esophageal function testing: Billing and coding update. Neurogastroenterol Motil. 2018;30:e13158. https://doi.org/10.1111/nmo.13158

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